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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The emergence of the SARS-CoV-2 virus led to immediate concerns about the impact of infection on pregnant women. In response to the SARS-CoV-2 pandemic the MBRRACE-UK team instituted rapid notification of maternal deaths associated with SARS-CoV-2, following which notifications of SARS-CoV-2-associated maternal deaths were received in early April 2020. Expedited reviews were conducted into all deaths of women with confirmed or suspected SARS-CoV-2 infection during or up to one year after pregnancy, and any deaths of women who died from mental health-related causes or domestic violence, which might have been influenced by public health measures introduced to control the epidemic such as lockdown. This rapid report aims to identify lessons learned to guide future care and pathway changes in the context of infection transmission and the need for public health and NHS service measures to prevent infection.
  2. Content Article
    Mesothelioma UK's Head of Nursing, Lorraine, interviews Clinical Nurse Specialists Anne and Chris from the Meso UK nursing team about their experiences of nursing during the COVID-19 pandemic. 
  3. Content Article
    This special Patient Safety Network Perspective compiles findings and insights into a series of case studies from interviews and written responses from leaders at three different health systems who had to increase their telehealth capacities in response to the COVID-19 pandemic. 
  4. Content Article
    Care Quality Commission (CQC) Chief Executive, Ian Trenholm, discusses the immediate priorities for CQC, what’s coming next with their Transitional Regulatory Approach, and further ahead to CQC's future strategy.
  5. Content Article
    How did it come to this? A virus a thousand times smaller than a dust mite has humbled and humiliated the planet’s most powerful nation. America has failed to protect its people, leaving them with illness and financial ruin. The breadth and magnitude of its errors are difficult, in the moment, to truly fathom. Ed Yong in an article in The Atlantic highlights how despite ample warnings the country was unprepared for a pandemic, and suggests it remains unprepared for the next one.
  6. Content Article
    Larouzee and Le Coze describe the development of the “Swiss cheese model” and the main criticisms of this model and the motivation for these criticisms.  The article concludes that the Swiss cheese model remains a relevant model because of its systemic foundations and its sustained use in high-risk industries and encourages safety science researchers and practitioners to continue imagining alternatives combining empirical, practical and graphical approaches.
  7. Content Article
    Worldwide, cervical cancer is one of the leading causes of death from cancer in women. Cervical cancer accounts for 2% of all new cancer cases in females in the UK (Cancer Research UK 2016) and is, generally, a preventable disease. The primary cause of cervical abnormalities and cancer is persistent or chronic infection with one or more of the high-risk (oncogenic) types of human papillomavirus (HPV). In most women and men who become infected with HPV, these infections will resolve spontaneously (without treatment). However, for a minority of women, the infection leads to abnormal changes to the cervix, which, if not treated, may progress to cancer 10 to 20 years later. Both understanding and identifying HPV are important public health concerns and form part of the UK National Screening Programme.
  8. News Article
    Millions of women and girls around the world have been left unable to access contraception and abortions amid the coronavirus crisis, a new report has found. A study by Marie Stopes International, which provides abortion and contraception services worldwide, warns 1.9 million women and girls lost their usual access to its contraception and safe abortion services in the first half of the year as a result of the global public health emergency. The abortion provider is preparing for 900,000 additional unintended pregnancies, 1.5 million extra unsafe abortions, and 3,100 additional pregnancy-related deaths after the disruption to services in the first half of the year. Dr Rashmi Ardey, of Marie Stopes, said: “Women’s needs do not suddenly stop or diminish during an emergency – they become greater. And as a doctor, I have seen only too often the drastic action that women and girls take when they are unable to access contraception and safe abortion. “This pandemic has strained healthcare services all over the world, but sexual and reproductive healthcare was already so under prioritised that once again women are bearing the brunt of this global calamity.” Read full story Source: The Independent,19 August 2020
  9. News Article
    Nearly three-quarters of coronavirus patients admitted to hospital suffer ongoing symptoms three months later, new research suggests. A total of 81 patients out of 110 discharged from Southmead Hospital in Bristol were still experiencing symptoms from the virus, including breathlessness, excessive fatigue and muscle aches, after 12 weeks. Many were struggling to carry out daily tasks such as washing, dressing or going back to work, the study found. The majority of patients reported improvements in the initial symptoms of fever, cough and loss of sense of smell, and most had no evidence of lung scarring or reductions in lung function. The findings are part of North Bristol NHS Trust's Discover project, which is studying the longer-term effects of coronavirus - so-called Long COVID. An intensive care doctor, Dr Jake Suett, told Sky News in June that he was still suffering COVID-19 symptoms three months after contracting the disease. Dr Jake Suett, 31, had no underlying health conditions but was still suffering chest pain, breathlessness, blurred vision, memory loss, a high temperature, concentration problems. Dr Rebecca Smith, from North Bristol NHS Trust, said: "There's still so much we don't know about the long-term effects of coronavirus, but this study has given us vital new insight into what challenges patients may face in their recovery and will help us prepare for those needs." Read full story Source: Sky News, 20 August 2020
  10. News Article
    Matt Hancock has extended four national data sharing orders which allow GPs and NHS organisations to share confidential patient information, as part of the ongoing response to the COVID-19 pandemic. The data sharing instructions were initially put in place in March when the pandemic broke out in earnest, and they were due to expire at the end of September. Under the arrangement GPs, NHS providers, NHS Digital, NHS England/Improvement, local authorities and the UK Biobank can share information about patients’ treatment and medical history - if doing so would help their response to COVID-19. The data sharing instructions have now been extended until 31 March next year. According to the Department of Health and Social Care’s update which notified organisations of the extension, NHS entities can share information for reasons such as helping to support the NHS Test and Trace service, identifying further patients at risk of COVID-19, and understanding information about patient access to health and adult social care services. Read full story (paywalled) Source: HSJ, 20 August 2020
  11. Content Article
    Research has shown that frontline staff understand the dangers of pressure sores but experience significant challenges in their attempts to prevent them. The research, undertaken by NHS Midlands and East and downloadable below, showed that staff feel they do not have the time to treat patients and need improved communication between the patients, their carers and the homes from which they might have come. In response to this, NHS Midlands and East has created the Pressure Ulcer Path, a tool to support staff in preventing pressure ulcers and treating them, alongside a number of useful resources.
  12. Content Article
    Although millions of patients with cancer around the world face delays in diagnosis and treatment because of the diversion of resources during the COVID-19 pandemic, there is a growing expectation that telemedicine may play a central role in easing the backlog. This Lancet Digital Health article explores how telemedicine will be key as healthcare systems move forward in tackling the backlog in not only cancer treatment but also diagnosis, and how augmented intelligence (AI) could be used to help to optimise its use.
  13. News Article
    A third of doctors have treated patients with long term COVID-19 symptoms, including chronic fatigue and anosmia, a survey conducted by the BMA has found. Richard Vautrey, chair of the BMA’s GP committee for England, said it was clear that the long term impact of COVID-19 on patients and the NHS would be profound. “With more patients presenting with conditions as the result of infection, it’s essential that sufficient capacity is in place to support and treat them,” Vautrey said. “With the growing backlog of non-COVID-19 treatment, the likelihood of a season flu outbreak, and the possibility of a second wave of infections we need to see a more comprehensive long term plan to enable doctors to care for their patients this winter and beyond.” The survey also asked doctors about their own experiences of COVID-19: 63% said they did not believe they had contracted the virus, 12% had had a diagnosis of COVID-19 confirmed by testing, and 14% believed they had been infected with the virus. David Strain, co-chair of the BMA’s medical academic staff committee, said that the NHS could not afford more failures of quality and supply in personal protective equipment. “Risk assessments should be available to all working in the NHS and appropriate steps should be put in place to mitigate the risk of catching the virus, even in those that have a low risk of a bad outcome from the initial infection,” he said. Read full story Source: BMJ, 13 August 2020
  14. News Article
    The number of adults experiencing depression has almost doubled during the pandemic, according to new figures. Data from the Office for National Statistics showed that almost one in five adults (19.2 per cent) were likely to be experiencing some form of depression in June. This had risen from around one in 10 (9.7%) between July 2019 and March 2020, before the imposition of the nationwide lockdown. Dame Til Wykes, a professor of clinical psychology and rehabilitation at King’s College London, warned of a looming “mental health crisis” once the pandemic passes. “This study tells us, yet again, that we might have a mental health crisis after this pandemic. The social effects of distancing and isolation for some affects their emotional wellbeing. Dr Billy Boland, chairman of the General Adult Faculty at the Royal College of Psychiatrists, said the UK’s mental health services would be faced with a “tsunami of referrals” in the coming months. “Isolation, bereavement and financial insecurity are some of the reasons why the nation’s mental health has deteriorated since the start of the pandemic. “The government must speed up the investment to mental health services if we are to treat the growing numbers of people living with depression and other mental illnesses.” Read full story Source: The Independent, 18 August 2020
  15. News Article
    High-risk women at a maternity unit were not monitored closely enough and there was a "lack of learning" from a mother's death, inspectors found. A Care Qualtiy Commission (CQC) report rated the unit at Basildon University Hospital as inadequate with "failings" found in six other serious cases. Inspectors carried out unannounced checks in June after a whistleblower voiced fears about patient safety. The unit was criticised following the deaths of baby Ennis Pecaku in September 2018 and mother Gabriela Pintilie, 36, in February 2019. The CQC previously carried out an inspection of the department the month Mrs Pintilie died and said the unit, which had once been rated outstanding, required improvement. Inspectors returned for the surprise "focused" inspection after being contacted by an anonymous whistleblower. The report found babies were born in a poor condition and then transferred for cooling therapy, which can be offered for newborn babies with brain injury caused by oxygen shortage during birth. During their visit, inspectors found: High-risk women giving birth in a low-risk area. Not enough staff with the right skills and experience. "Dysfunctional" working between midwives, doctors and consultants, which had an impact on the "increased number of safety incidents reported". Concerns over foetal heart monitoring. Women being referred to by room numbers instead of their names. A "lack of response by consultants to emergencies" resulting in delays The CQC also referred to issues relating to the death of Mrs Pintilie, who was not named in the report, and said five serious incidents "identified the same failings of care". Read full story Source: BBC News, 18 August 2020 "This demonstrated there had been a lack of learning from previous incidents and actions put in place were not embedded."
  16. News Article
    Leaders of US ECRI and its affiliate, the Institute for Safe Medication Practices (ISMP), announce the launch of a joint Patient Safety Organization (PSO), an important step in making medication, medical devices, and healthcare practices safer for patients across all care settings, now during the COVID-19 pandemic, and into the future. Read full story Source: CISION PR Newswire
  17. News Article
    A quiet revolution in the NHS has happened. After decades of an internal market, NHS England has outlined new changes tying financial allocations and incentives to system-level performance instead. Over the past six months, providers had been allocated block funding based on activity from 2019/20 with top-ups and retrospective funding to support covid pressures, ensuring they financially break even during the crisis. Now, in a letter accompanying funding envelopes for Integrated Care Systems and Sustainability and Transformation Partnerships around the country, NHSE outlined how health service finances will be system managed for the remainder of the year. Systems will have not only control of the kitty (with all system costs to be met from its allocation) but funding will be linked to the performance of their member organisations, with some incentive payments or penalties for over/under performance at a system level. Glen Burley, the chief executive of a group of three acute trusts in the West Midlands, branded the move “very risky” and suggested a more traditional tariff performance would drive performance. Highlighting another of his concerns he said: “We have very little experience of doing so at system level, so this is a very risky tactic in a very risky year.” How systems will manage the shortfalls will hinge on elective delivery, system co-ordination, how to reduce forecast costs and recover income, set, of course, against the threat of a second wave of COVID-19. Read full story Source: HSJ, 17 September 2020
  18. Event
    until
    ISQua have assembled the leading speakers in the field of patient safety, including Hardeep Singh, Stephen Muething, Johanna Westbrook and John Ovretveit to name but a few. The virtual conference is scheduled to last for 2 hours each day. It will consist of three different sessions: a plenary-style talk, 4 Pecha Kucha style presentations and a networking session. Find out more and register
  19. News Article
    Following four deaths and more than 300 incidents with steroid replacement therapy involving patients with adrenal insufficiency in the past two years, patients at risk of adrenal crisis will be issued with a steroid emergency card. All adults with primary adrenal insufficiency (AI) will be issued an NHS steroid emergency card to support early recognition and treatment of adrenal crisis, a National Patient Safety Alert has said. The cards will be issued by prescribers — including community pharmacists — from 18 August 2020. AI is an endocrine disorder, such as Addison’s disease, which can lead to adrenal crisis and death if not identified and treated. Omission of steroids in patients with AI, particularly during physiological stress such as an additional illness or surgery, can also lead to an adrenal crisis. The alert has requested that “all organisations that initiate steroid prescriptions should review their processes/policies and their digital systems/software and prompts to ensure that prescribers issue a steroid emergency card to all eligible patients” by 13 May 2021. Read full story Source: The Pharmaceutical Journal, 17 August 2020
  20. Content Article
    A joint National Patient Safety Alert has been issued by NHS Improvement and NHS England national patient safety team, Royal College of General Practitioners, Royal College of Physicians and Society for Endocrinology, regarding the introduction of a new Steroid Emergency Card to support the early recognition and treatment of adrenal crisis in adults.
  21. Content Article
    Tools and resources to support the implementation of the WHO Guidelines on Core Components of Infection Prevention and Control Programmes.
  22. News Article
    Thousands of patients with cancer have had chemotherapy delivered to their doors so that they can more safely receive treatment during the coronavirus pandemic. Up to 10,000 chemo home deliveries were made over three months at the peak of the outbreak, avoiding the need for patients to venture out and risk infection when their immune system was low. The drops are part of the COVID-friendly treatments introduced in response to the pandemic which have helped to ensure that 85,000 people could start treatment between March and June, with latest data showing referrals beginning to recover to pre-pandemic levels. NHS staff, including community nurses and pharmacists, and volunteers have been dropping off the life-saving medication – they step back two metres when they arrive at a patient’s house, identify them and make sure they have everything they need. Hospitals have also significantly increased the use of chemo at home, with local pharmacy teams and community nurses providing the service to reduce cancer patients’ risk of exposure to the virus. The action joins a series of measures, including the rollout of COVID protected cancer hubs for treatment and introducing ‘COVIDfriendly’ cancer drugs. NHS England is spending £160 million on drugs that mean patients do not have to go to hospitals for regular checks and treatment. Dame Cally Palmer, director of cancer for the NHS in England said: “NHS staff have treated more than 108,000 patients requiring specialist hospital care for COVID-19 while also keeping other vital services such as cancer, maternity and A&E running throughout the pandemic. “The NHS has also fast tracked modern, more convenient services that help to keep patients and staff safe – from video consultations to chemotherapy delivered to patients’ doors – that have allowed 85,000 people to start cancer treatment during the pandemic.” Read full story Source: NHS Improvement, 17 August 2020
  23. News Article
    Nurses and non-medical staff have been stopped from taking patient calls to the NHS coronavirus helpline amid concerns over the safety of their advice. An audit of calls to the telephone assessment service found more than half were potentially unsafe for patients, according to a leaked email shared with The Independent. At least one patient may have come to harm as a result of the way their assessment was handled. The COVID-19 Clinical Assessment Service (CCAS) is a branch of the NHS 111 phone line and is designed to assess patients showing signs of coronavirus to determine whether they need to be taken to hospital or seen by a GP. The helpline was set up at the start of the pandemic to divert patients with symptoms to a phone-based triage to relieve pressure on GPs and prevent them from turning up at surgeries and spreading the virus. GPs, nurses and allied health professionals (AHPs) such as paramedics and physiotherapists were recruited to speak to patients after they were flagged by NHS 111 call handlers. The use of non-medical staff was first paused in July amid concerns about the quality of call handling. Now it has emerged much wider safety issues have surfaced. Read full story Source: The Independent, 18 August 2020
  24. News Article
    Almost 7,000 patients have waited for treatment for a year or more at a major north London trust, according to NHS data seen by HSJ. Royal Free Foundation Trust had 6,875 patients waiting 52 weeks or more, as of 26 July, according to a leaked document. It stopped reporting its elective waiting list to the centre in February 2019, citing concerns over accuracy. In a statement, it said these concerns continue. But the document suggests the Royal Free accounted for around a third of the 20,000 year-long waiters across London at the end of July. Minutes from the May meeting of the trust board’s quality, finance and compliance committee acknowledged “there was now a large number of RTT 52 week waiters on the trust patient tracking list… due to much of the elective work having been cancelled during covid-19, and these numbers were growing”. Read full story (paywalled) Source: HSJ, 18 August 2020
  25. News Article
    A major British medical school is leading the drive to eliminate what it calls "inherent racism" in the way doctors are trained in the UK. The University of Bristol Medical School says urgent action is needed to examine why teaching predominantly focuses on how illnesses affect white people above all other sections of the population. It comes after students pushed for reform, saying gaps in their training left them ill-prepared to treat ethnic minority patients – potentially compromising patient safety. Hundreds of other UK medical students have signed petitions demanding teaching that better reflects the diversity of the country. The Medical School Council (led by the heads of UK medical schools) and the regulator, the General Medical Council, say they are putting plans in place to improve the situation. A number of diseases manifest differently depending on skin tone, but too little attention is given to this in training, according to Dr Joseph Hartland, who is helping to lead changes at the University of Bristol Medical School. "Historically medical education was designed and written by white middle-class men, and so there is an inherent racism in medicine that means it exists to serve white patients above all others," he said . "When patients are short of breath, for example, students are often taught to look out for a constellation of signs – including a blue tinge to the lips or fingertips – to help judge how severely ill someone is, but these signs can look different on darker skin." "Essentially we are teaching students how to recognise a life-or-death clinical sign largely in white people, and not acknowledging these differences may be dangerous," said Dr Hartland. Read full story Source: BBC News, 17 August 2020
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